Reports

Other CQC inspections of services

Inspection carried out on 21-23 March 2017, 27-28 March 2017 and 3 April 2017

During a routine inspection

We carried out an announced inspection between 21 and 23 March 2017 and an unannounced inspection at Great Western Hospital on 27 and 28 March 2017 and 3 April 2017. This was a focused inspection to follow up on concerns from a previous inspection. As such, not all domains were inspected in all core services.

The inspection team inspected the following six core services at Great Western Hospital:

Urgent and emergency services

Medical care (including older people’s care)

Surgery

Critical care

Services for children and young people

Outpatients and diagnostic imaging

We also inspected:

Urgent care services (provided as a community service).

We did not inspect end of life care or maternity and gynaecology services (previously rated good). We did not inspect the effective, caring or responsive domains for services for children and young people (previously rated good). The effective domain was inspected but not rated for outpatients and diagnostic imaging.

Overall we rated Great Western Hospitals NHS Foundation Trust as requires improvement.

Safe

We rated the safe domain as requires improvement overall. Urgent and emergency services, medical care, surgery, critical care, services for children and young people and outpatients and diagnostic imaging were all rated as requires improvement.

As a result of high demand we found the emergency department was frequently full, with patients in all cubicles and around the nurses’ station. There were occasions where the emergency department was deemed to be unsafe as a result of the number of patients within the department. However, this was improving. We also found that as a result of pressures for beds in surgery some patients had to use facilities which were not always suitable for recovering from their surgery.

Compliance with safe systems to ensure medicines were stored at the correct temperature needed to be improved. Daily checks of medicines were not always completed in the emergency department or critical care. We found in medical care that some areas did not have regular temperature checks. This meant there was limited assurance that medicines were being stored within required temperature ranges to ensure they were fit for use.

The storage of medicines needed to be improved. In medical care we found that some of the storage shelves did not allow for stock rotation, which increased the risk of medicines being out of date. We also found in critical care that the fridges used to store medicines could not be locked. This meant that medicines could be removed without authorisation.

Equipment used was not always checked in line with guidance to ensure it was fit for purpose. Daily checks of emergency equipment did not always take place. In services for children and young people that heated water blankets did not have expiry dates or water change dates recorded.

There were areas throughout the hospital which did not have sufficient numbers of suitably qualified staff on duty to keep people safe. This included the emergency department observation unit where we observed a patient walking out of the department without staff knowing. Within medical care and surgery, services for children and young people and critical care there were wards and theatres which went through periods of understaffing, which meant that staffing numbers did not always meet national guidelines. In medical care we found that ambulatory care was sometimes left with no staff in it for short periods of time due to lone working arrangements.

Mandatory training rates needed to be improved in the emergency department for medical staff, in medical care, outpatients and diagnostic imaging, critical care, and surgery. In services for children and young people all medical staff fell below trust targets for all mandatory training and paediatric basic life support training was below target in all staff groups.

Safeguarding practices needed to be improved in outpatients and diagnostic imaging and in services for children and young people. In outpatients and diagnostic imaging only 20% of medical and dental staff had completed level two safeguarding adults training against a trust target of 80%. In services for children and young people staff did not have ready access to relevant safeguarding information on a patient due a filing backlog.

The security and completeness of records needed to be improved. We found in medical care and critical care that patient records were not always stored securely. We also found that in critical care patient allergies and venous flushes were not always documented. In medical care we found that not all patient documentation was completed in full and handovers between wards was not consistency provided to a high standard. This meant that patients' full needs may not always be met.

However:

There was a positive incident reporting culture. Openness and transparency was encouraged. Opportunities for learning were sought when an incident occurred and learning was shared between teams. Where never events occurred in surgery we found they were investigated fully and actions had been taken to prevent them from happening again.

We found all areas within the hospital, with a few exceptions, were visibly clean and tidy. Staff followed National Institute of Health and Care Excellence standards for hand hygiene and audit results were positive.

We found that staffing levels for both medical and nursing staff were in line with recommended guidance in the emergency department, and critical care. Within medical care there were sufficient doctors to provide safe care for patients.

Risks to people who use services were appropriately assessed in the emergency department where we found observations and treatment decisions were made in a timely way. We found that patients' records were legible, complete, up to date and accurate in the emergency department, surgery, and critical care.

Effective

We rated the effective domain as good overall. It was rated as good for urgent and emergency care, medical care, surgery, critical care. It was inspected but not rated for outpatients and diagnostic imaging.

In the emergency department, medical care, surgery, services for children and young people, critical care and outpatients and diagnostic imaging we found that patients' care and treatment were planned and delivered in line with guidance, standards, best practice and legislation. This included guidance from the National Institute of Care Excellence and the Royal College of Emergency Medicine.

Information about people’s care and treatment was routinely monitored and action was taken to improve the effectiveness of treatment where shortfalls had been identified. In surgery the trust had a better rate for re-admission compared to the national average. The emergency department performed well in the latest Royal College of Emergency Medicine audits. In services for children and young people outcomes were either in line with or better than the national average.

Staff had the skills required to carry out their roles effectively. In all services we inspected we found that staff had qualifications, experience and had received competency training in line with their role requirements. Most services performed better than the trust target for completion of appraisals.

Patients received care and treatment from different disciplines who worked together in a coordinated way. All departments communicated well with each other to ensure effective treatment for patients. This multidisciplinary working approach continued over weekends where there were 24 hour diagnostics, critical care outreach, physiotherapy, pharmacy, and mental health liaison services.

Within all services we found that the nutrition and hydration needs of patients were fully assessed and that actions were taken to address concerns as soon as they were identified. Within the trauma unit innovative systems were in place to improve nutrition and hydration for patients.

However:

In some areas of the trust outcomes required improvement. In medical care areas of the national stroke audit, MINAP audit and the national heart failure audit required improvement.

In critical care the provision of therapy services did not meet national standards. We found there was insufficient access to physiotherapy and dietetic services.

In all areas feedback from patients was consistently positive. Patients, relatives and carers told inspectors they had received care that was compassionate, they had been involved as partners in care, and they were supported to cope emotionally with their care.

Inspectors observed patients being treated with kindness and respect and saw that patients and their relatives were active partners in their care. They were well informed of treatment options and were involved in decision making.

Emotional support was available to patients. Staff took time to sit with patients and talk to them. A psychiatric liaison nurse was available to provide psychological support. There were good examples of staff listening and acting supportively to patients suffering from emotional distress.

However:

Privacy and dignity was compromised in the discharge lounge, the surgical assessment unit, theatre recovery, and ophthalmology. Conversations with patients could be overheard in the discharge lounge

and in the

ophthalmology department. We found that in the surgical assessment unit, the discharge lounge and theatre recovery, privacy was difficult to maintain when a patient required the toilet or to use a bedpan.

Responsive

We rated the responsive domain as requires improvement overall. It was rated as requires improvement for urgent and emergency care, medical care, surgery and outpatients and diagnostic imaging. It was rated as good for critical care.

Patient flow through the hospital required improvement. The trust found it difficult to discharge patients from medical, surgical, and critical care services who required social care or patients who had a complex discharge.

This resulted in the emergency department regularly being full to capacity, which meant that patients could not be seen in a timely way for assessment or treatment. The emergency department regularly breached targets for time spent in the department, with most breaches being attributable to unavailability of beds in the hospital.

Although medical outliers were managed well, the number of them impacted on the number of elective operations which could take place.

Facilities were not always fit for purpose, as a result of the numbers of patients being treated at the hospital. The medical expected department was not always able to separate male and female patients, which compromised privacy and dignity. In the emergency department patients were regularly accommodated around the nursing station without screens to protect their dignity.

For three months out of the past 10 the trust was performing worse than the national standard for two week urgent cancer referrals There were a high number of patients waiting for non-cancer outpatient appointments, with the most in ophthalmology. There were also delays in sending out of letters to patients after their appointment.

In medical care and outpatients and diagnostic imaging translation services were available, but they were not always utilised. In medical care relatives were sometimes used to translate, which compromised confidentiality.

However:

A number of steps had been taken to improve patient flow. This included re-locating the ambulatory care service to increase capacity and the introduction of the medical expected unit. There were also effective patient flow meetings to establish who could be discharged.

High numbers of patients were streamed from the emergency department to the urgent care centre.

Reasonable adjustments were made to support patients in vulnerable circumstances throughout the hospital. Staff had a good understanding of the adjustments needed to support people living with dementia and patients with learning disabilities.

Well Led

We rated the well led domain as requires improvement overall. It was rated as good for urgent and emergency care, medical care, critical care, and outpatients and diagnostic imaging. It was rated as requires improvement for surgery and services for children and young people.

Services for children and young people felt disconnected from the rest of the trust. The leadership had not been embedded locally and there was no representation of services for children and young people on the board.

Nurses in services for children and young people did not recognise the trust as a good place to work. We were told that they often had to work long hours without access to a drink and without having a break. Nurses did not know the strategy of the women’s and children’s division.

In the emergency department, and surgical services staff felt that the executive team was not visible enough and that attempts to engage with staff could be better.

In surgery there were areas where there was a lack of management oversight. Also, actions identified to mitigate risks on the risk register were not always effective.

However:

There was a clear vision and strategy within the services which was underpinned by realistic goals. This strategy was being acted upon with innovative workstreams through the emergency department, medical care, surgery, services for children and young people and outpatients and diagnostic imaging.

Governance functioned effectively in all of the core services we inspected and where reviews were underway (in services for children and young people), there were clear action plans.

Leaders of services throughout the organisation had a good understanding of the challenges in their departments and had the knowledge, skills and experience to lead effectively. Staff throughout the organisation spoke positively about their leaders and were confident to go to them if they had concerns or they required support.

We saw several areas of outstanding practice, including:

The work of the education lead in the emergency department to improve education through various initiatives and work steams, including improved appraisals, training as part of the governance days and introduction of structured workbooks and teaching sessions.

The understanding and involvement of patients and those close to them in the paediatric emergency department during triage. We observed that the nurse put the patient at ease and made sure that the process was explained in a compassionate way.

The understanding of the emergency department leadership team of performance, governance, risks and its impact on patient care.

The use of an emergency department monthly governance day to engage staff with governance and learning from incidents, concerns or near misses.

The use of social media in the emergency department to engage staff to be more engaged with governance, share learning and discuss concerns with senior members of staff.

The work of the clinical trials team in the emergency department to increase trial recruitment from very few patients a year to several hundred patients a year and the impact this has had on patient experience in the department.

The medical care and outpatients services had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

The medical care and outpatients services had introduced digital technology for patients living with dementia, which enabled them to access personalised reminiscence material.

The trauma unit within surgery provided a picture menu which showed photographs of all food options that the hospital provided. This could be used for non-verbal patients or patients with learning disabilities so they could more easily identify what food they would like at mealtimes. This had been hugely successful on the ward and at the time of the inspection this was being rolled out across the hospital.

The trust had introduced acute neurology clinics, located close to the short stay/ambulatory care unit, for patients who attended the acute medical unit and would have needed to be admitted in the past for further opinions and tests. These patients could now be discharged with an appointment, either the following day or the day after. This initiative had led to a significant number of admissions being avoided and provided a positive experience for patients.

The cardiology department inserted the first four lead pacemaker for a patient in the world. The medical staff were monitoring the patient’s recovery and rehabilitation as part of an international research project to assess the advantages of the new technology.

A GP was employed in ambulatory care four days a week. The purpose of this new position was to improve communication with GPs to ensure basic tests had been completed prior to the patient attending the ambulatory care unit. It was anticipated that this would help to increase the flow of patients through the department and prevent patients attending the unit unnecessarily.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure that the emergency department observation unit is sufficiently staffed to keep people safe.

Ensure that medical staff in the emergency department receive appropriate mandatory training to enable them to carry out the duties they are employed to perform.

Ensure that daily checks are conducted on resuscitation equipment and medicine fridges in the emergency department to assess that they are safe to use.

Continue to develop and initiate plans and work streams in line with the improvement plan to improve flow in the emergency department at pace to improve safety and patient flow in the department.

Ensure the promotion and control of infection at all times and in all areas within medical care.

Ensure the security of patients’ confidential and personal information at all times within medical care.

Ensure the safety of patients at all times within medical care, including ensuring sufficient staff are on duty to monitor and provide care and treatment to patients. The trust should ensure patients are not left unattended in the ambulatory care department as a result of staff lone working.

Ensure that the privacy and dignity of patients in medical care is respected and ensure that breaches of the national mixed sex accommodation standard do not occur.

Ensure that handovers take place consistently in medical care when transferring patients between wards and departments. The trust should ensure that patients are assessed promptly by doctors following admission to the medical expected unit.

Ensure that there are clear pathways in medical care, including staffing levels, regarding the care of patients who require non-invasive ventilation (NIV).

Improve the timely completion of discharge letters to GP’s, including reducing the large backlog of letters which have not been sent within surgery.

Ensure that in critical care there are adequate allocated hours from allied healthcare professionals to meet national recommendations.

Ensure there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff in areas where children are cared for, in line with national guidance.

Ensure all staff involved with the care of children are up-to-date with paediatric basic life support and mandatory training.

Ensure medical and dental staff in outpatients and diagnostic imaging have received training in level two safeguarding vulnerable adults.

Ensure medical and dental staff in outpatients and diagnostic imaging are up to date with mandatory training, including adult basic life support, fire training and paediatric life support

In addition the trust should:

Ensure that there are suitable quantities of cardiac monitors and trolleys in the emergency department to ensure that they keep people safe at times of crowding.

Ensure that alcohol and substance misuse support is available in the emergency department for patients who require it.

Ensure that the executive team is more engaged with staff in the emergency department and plan times of visits better to prevent a negative impact on staff morale.

Ensure that equipment used for personal care within medical care services is fit for purpose and that staff can provide assistance promptly if the patient becomes unwell while using equipment. This relates to showers which were not easily accessible.

Ensure that clinical equipment in medical care, such as needles and blades, is stored securely.

Ensure the safe storage of medicines, including creams and ointments at all times. This should include ensuring that medicines are stored in accordance with manufacturers' guidelines.

Ensure that where oxygen cylinders are stored in medical care, there is appropriate signage to inform staff and visitors to the area.

Ensure that staff working in all departments in medical care have access to emergency equipment and medicines in order to be able to respond promptly to medical emergencies.

Ensure within medical care that care documentation, including care plans, and risk assessments, are completed in sufficient detail to inform staff of the individualised care and treatment that is required for each patient.

Ensure that nursing staffing levels in medical care consistently meet the assessed and agreed staffing establishment for all wards and departments.

Ensure that within medical care performance against national audits is improved.

Ensure that within medical care patients' confidentiality is consistently respected when they require assistance with interpretation and/or translation.

Ensure that within medical care the complaints process is followed in a timely way and in accordance with the trust policy and procedure.

Ensure that staff within medical care are consistently informed and knowledgeable about the risk registers for their wards and departments.

Improve the completion of NEWS within surgery.

Improve referral to treatment time target compliance for surgical patients.

Ensure fabric curtains in critical care are replaced by disposable curtains to meet national standards.

Ensure there are processes to monitor and audit compliance with cleaning processes in critical care.

Ensure effective processes are put in place in critical care to learn from mortality and morbidity meetings.

Ensure staff in critical care check essential equipment daily in line with policy.

Ensure that in critical care, patients’ allergies are always documented and that staff sign for all medicines they administer.

Ensure practice guidance is regularly reviewed and updated in critical care to comply with national recommendations.

Review the training and competency assessment of medical staff in critical care to ensure there are always staff on duty that are competent in airway management.

Review nurses' paediatric competencies and training in critical care, to ensure they are up-to-date and current.

Explore the improvement of the patient toilet in critical care to include shower facilities so that these facilities are not shared with relatives.

Review the arrangement in critical care for the provision of follow-up clinics to ensure these are sustainable.

Ensure staff have access to appropriate equipment necessary in children’s services to carry out their roles and provide care effectively and efficiently.

Ensure all staff involved in the care and assessment of children and young people have safeguarding training in line with intercollegiate guidance.

Ensure that systems are in place to ensure case conference notes of vulnerable children are filed in their records in a timely manner.

Consider the wellbeing of staff within children’s and young people’s services in terms of regular access to rest breaks and hydration.

Consider mechanisms which could improve the connection of, and communication between, front line staff and divisional leaders within children’s and young people’s services.

Consider options for improving the connection between the women and children’s division and the rest of the trust, and review the representation of children’s services at board level.

Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.

Ensure that departments within outpatients have access to resuscitation equipment in line with hospital policy.

Provide patient information leaflets within departments in outpatients and diagnostic imaging that are available in different languages.

Ensure access for bariatric patients in outpatients is improved so patients can be assessed and treated without compromising their privacy.

Make improvements on the follow up backlog waiting list to meet people’s needs and minimise possible risk and harm caused to patients through excessive waits on outpatient appointments and excessive waits on the reporting of images.

Make improvements on the backlog in typing time times in outpatients and the delay in letters being sent to GPs.

Ensure arrangements are in place to replace aging diagnostic imaging equipment identified at risk of failure.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During a routine inspection

We previously visited the Great Western Hospital in September 2015 when we carried out a comprehensive inspection of the services provided. We raised a number of concerns following this inspection in relation to the emergency department. Our concerns in relation to safety were significant and we judged that the governance systems and processes in place were not effectively operated and, as such, were not able to demonstrate effective management of risks, effective clinical governance, continuous learning, improvements and changes to practice from reviews of incidents, complaints and mortality and morbidity reviews.

In December 2015, in light of these concerns, we took enforcement action and required the trust to make significant improvements. The trust submitted a comprehensive improvement plan and provided us with monthly progress reports.

In April 2016 we carried out an inspection to check progress against the concerns raised in the warning notice. We found that significant progress had been made but the requirements of the warning notice were not fully met. Our remaining concerns were:

Risks to patient safety were not always addressed in a timely way.

Accurate and up-to-date records of care and treatment were not consistently maintained to ensure that patients were protected against the risk of inappropriate care and treatment.

Staff did not consistently comply with safety systems in place to identify seriously unwell or deteriorating patients.

The emergency department was not consistently staffed to ensure that defined safe staff to patient ratios were met. There was insufficient reporting or scrutiny of staff concerns with regard to staffing levels and capacity.

We had continuing concerns about the safety of patients and staff in the emergency department observation unit. Plans to relocate or reconfigure the unit to improve safety had not been finalised.

There remained a significant number of gaps in nurse training. A training plan to address identified gaps had not been developed and management oversight of this had yet to be implemented.

In October 2016 we conducted a second follow up inspection of the emergency department. At the time of this visit, we were aware that the emergency department and the hospital had continued to experience unprecedented demand for unscheduled care. This was reflected in the trust’s performance against key targets. In the period July to September 2016 the trust consistently failed to meet the following targets:

85% of patients were triaged within 15 minutes of arrival (patients arriving by ambulance) against a target of 95%;

The median time patients waited to be seen was 70 minutes, compared with the target of 60 minutes;

80.1% of patients were discharged, transferred or admitted within four hours, compared with the target of 95%.

We found that further and sufficient progress had been made to meet the requirements of the warning notice. Our key findings were as follows:

Record keeping had improved through ongoing training and coaching. Audits showed an improving picture in relation to the frequency with which staff observed patients’ vital signs and calculated early warning scores to identify deteriorating patients.

There was improved oversight of staffing, capacity and safety in the emergency department by the nurse in charge. Regular situation reports had been introduced and these ensured managers were informed of risks and concerns were escalated. Steps were being taken to reduce the risks associated with the employment of temporary staff. The department was exploring innovative ways to improve staff recruitment and retention.

Governance systems had been further strengthened. Risks were well understood and regularly discussed. Audits were used to drive service improvement. There was greater oversight of nurse staff training and supervision.

Steps had been taken to better equip staff to care for mental health patients on the observation unit. Plans had been agreed to make alterations to the premises to create a safer environment for patients and staff. Incidents relating to the management of mental health patients had reduced significantly.

However, there were also areas where the trust needs to make further improvements:

We had continuing concerns that the emergency department was not able to consistently meet defined safe staff to patient ratios at times of overcrowding. Staff shortage was a continuing problem and there were concerns about a lack of senior and experienced nursing staff. There was heavy reliance on temporary staff and there were concerns about their competence. Notwithstanding the risk this posed to patient safety, this affected staff morale, recruitment and retention.

We were concerned about a lack of pace in addressing risks identified by a serious incident which occurred in May 2016. We were also concerned that learning had not been embedded in staff practice following a similar incident which occurred in 2014. Staff awareness of risks and learning from adverse events needed to improve.

Despite improvements in record keeping, we judged there was room for further improvement and consistency, to ensure that patients are protected against the risk of inappropriate care and treatment.

Professor Sir Mike Richards

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During an inspection to make sure that the improvements required had been made

We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served on the trust in December 2015. This followed our comprehensive inspection of the trust in September 2015. The warning notice set out the following areas of concern where significant improvement was required:

The location, design and layout of the emergency department observation unit, combined with inadequate staffing levels and staff training, presented risks to patients and staff.

Systems to ensure accurate records were maintained in respect of patients’ care and treatment were not effective. We could not be assured appropriate care and treatment was provided in a timely manner.

There was a lack of assurance that nurse staffing levels had been appropriately established or that planned levels of staffing were consistently achieved to ensure that patients attending the emergency department received timely, safe and effective care and treatment.

There were insufficient numbers of staff employed in the children’s emergency department who had received appropriate training to equip them to care for children. Planned staffing levels were not consistently maintained. This, combined with the design and layout of the department, presented unacceptable risks to patients. These risks were not addressed and steps to mitigate risks were not adequate or effective to ensure safe care and treatment.

There was inadequate oversight and monitoring of staff training to ensure that staff had the right qualifications, skills, knowledge and experience to provide appropriate care and treatment in a safe way

The governance systems and processes in place within the trust were not effectively operated and as such were not able to demonstrate effective clinical governance, continuous learning, improvements and changes to practice from reviews of incidents, complaints and mortality and morbidity reviews. This was particularly evident in the unscheduled care division and the planned care division.

The trust was required to make significant improvements by 31 January 2016. The action plan provided by the trust, detailing how improvements would be made, indicated that full compliance would not be achieved until April 2016.

The inspection was conducted on 21 and 22 April 2016 and was unannounced. Our inspection focused on the issues identified which occurred in the following areas:

The emergency department, including the observation unit

Governance arrangements in the planned care and unscheduled care divisions

The reporting period coincided with a very busy and challenging time for the emergency department and the hospital. The winter had seen a significant increase in ED attendances and unplanned admissions to hospital. This was compounded by significant staff shortage, ward closures due to infection and a high number of delayed discharges. Poor patient flow within the hospital and the wider health and social care community meant that the ED was frequently overcrowded and patients spent too long in the department. This was demonstrated by the consistent failure of the four hour target and the unprecedented number of patients waiting 12 hours or more for a hospital bed.

We had continuing concerns that safety concerns were not always addressed in a timely way. Key findings were as follows:

Accurate and up-to-date records of care and treatment were not consistently maintained to ensure that patients were protected against the risk of inappropriate care and treatment.

Staff did not consistently comply with safety systems in place to identify seriously unwell or deteriorating patients.

The emergency department was not consistently staffed to ensure that defined safe staff to patient numbers were met. There was insufficient reporting or scrutiny of staff concerns with regard to staffing levels and capacity.

We had continuing concerns about the safety of patients and staff in the emergency department observation unit. Plans to relocate or reconfigure the unit to improve safety had not been finalised.

There remained a significant number of gaps in nurse training. A training plan to address identified gaps had not been developed and management oversight of this had yet to be implemented.

However,

Comprehensive improvement plans were in place and progress against these plans was overseen by executive management. Progress had been made against milestones.

In recognition of the significant improvement agenda, temporary management support had been provided to the management team within the emergency department.

Nurse staffing had been increased by approximately 20%. This included provision of staff to improve safety in the children’s emergency department and in the observation unit.

Staff had received specialist training to better equip them to care for patients with mental health needs who were at risk of causing harm to themselves or others. Security presence had been increased in the emergency department.

Governance systems had been strengthened and reporting improved so that divisional and executive management had a more comprehensive overview of risks to safety and quality.

Whilst improvements had been made, the ongoing concerns identified during the follow up inspection mean the Warning Notice dated 2 December 2015 has only been partially met.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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Inspection carried out on 29 September - 2 October and 11, 12, 15 October 2015

During a routine inspection

Great Western Hospitals NHS Foundation Trust consists of one acute hospital (Great Western Hospital) and four community hospitals, of which three provide inpatient services. There are a total of 450 acute beds (including 12 critical care beds and 38 maternity beds) at the Great Western Hospital. Chippenham Hospital has 37 beds spread over two wards, there is one ward of 25 beds at Warminster Hospital and one ward of 26 beds at Savernake Hospital. The trust provides acute and community healthcare services to a population of around 480,000 people from Wiltshire and the surrounding areas.

Overall, Great Western Hospitals NHS Foundation Trust was rated as requiring improvement. We rated it as good for caring and as requiring improvements in safety, effectiveness, being responsive to patients’ needs and being well-led. Maternity and gynaecology services and end of life care were rated as good overall with all other core services rated as requiring improvement. We rated safety within urgent and emergency care as inadequate. Three of the four community services inspected were rated as good in all domains. We rated the children and young people’s services within the community as outstanding.

Our key findings were as follows:

Safety

Patients were not consistently protected from avoidable harm. Safety was inadequate in urgent and emergency services, and required improvement in all other services except end of life care where we rated it as good.

Capacity and overcrowding presented significant challenges in the emergency department, which resulted in patients not always been cared for in the most appropriate part of the department.

Risks to patients were not always appropriately assessed and their safety monitored and maintained. Self-presenting patients in the emergency department did not always receive prompt initial assessment (triage). In inpatient areas, risk assessment tools for identifying risks of thrombosis, pressure damage, moving and handling, nutritional and falls were not consistently completed. Patient observations were not consistently undertaken with the required frequency to ensure that any deterioration in a patient’s condition was identified.

There were shortfalls in the levels of nursing staff across the hospital. There were high numbers of vacancies in some areas and although bank and agency staff were used, not all shifts were covered to provide a full cohort of staff. This was of particular concern in the emergency department where the staffing levels did not take into account the need to care for patients who queued in the corridor or sub waiting room. Also, the level and skill of staff working the children’s emergency area and the observation unit were not appropriate at all times.

The number and grade of medical staff at the trust was comparable with the national average.

The location, design and layout of the emergency department observation unit was not suitable for the care of patients with mental health needs who presented challenging behaviour or were at risk of harming themselves and/or others.

Staff were aware of how to report incidents but there were times when they were too busy to do so and they were not always reporting near misses. Situations such as staff shortages and waiting times had become normal and staff did not always complete incident forms in these circumstances. The trust reported a lower number of incidents per 100 admissions compared to the England average.

Learning from incidents was not taking place in all areas, nor were the benefits of learning from serious incidents being shared in all areas or across the hospital.

There were areas of concern with infection control practices. Although overall the environment was clean and tidy there were some exceptions to this. In the dermatology department there was dust and debris on high surfaces. In the day surgery unit there was debris on the floor and the female toilet was unclean, and in the critical care unit there was dried staining on beds and a commode. Staff were not consistently adhering to good hand hygiene practices or using protective personal clothing such as aprons and gloves when required. There had been 12 reported cases of Clostridium difficile up to the end of July 2015, therefore the trust was at risk of breaching its annual trajectory of 20 for the 2015/16 year.

The management of patients with mental health issues was not fully considered. For patients with a high risk of attempting suicide consideration of ligature risks on the ward were not recorded.

There was considerable variety in the quality of patient’s records in the medical wards. The records were not fully completed nor did they provide detailed information for staff regarding the care and treatment needs of patients.

Not all areas of the premises were safe and secure, with possible access to confidential records.

Equipment was not always appropriately and safely stored. Some equipment was also becoming unreliable or outdated, such as the decontamination and sterilisation equipment and equipment for measuring patient’s visual fields. Not all maintenance checks were in date.

Chemicals and substances that are hazardous to health (COSHH) were observed in areas that were not locked and therefore accessible to patients and visitors to the wards. Cleaning materials including chlorine tablets were in the sluices, which were unlocked.

Sharps bins were in place throughout the medical wards and departments for the safe disposal of used needles and other sharp equipment. However, we observed these were not used in accordance with manufacturer’s guidance as they were not consistently closed when in use and some were over two thirds full and still being used. This meant staff were at risk of a needle stick injury.

Medicines were not always appropriately managed with weaknesses in safe and secure storage, and medicine reconciliations had not been achieved in line with guidance or trust policy.

The hospital was not meeting the trust target of 80% of staff receiving mandatory training; therefore we were not assured that staff were up to date with safe systems, processes and practices.

Staff understood their responsibilities and were aware of the safeguarding policies and procedures and the processes for reporting suspected abuse.

The trust had a major incident and business continuity plan in place. The majority of staff were aware of their roles and responsibilities should the plan be activated.

Effective

In most services, people’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based guidance.

Information about patient outcomes was collected and monitored, with the trust participating in a number of national audits so it could benchmark its practice and performance against that of other trusts. Although action plans were available for the majority of areas where improvement was required, these were frequently incomplete so progress could not be assured.

Patient’s pain was generally assessed and well managed. The exception to this was in the emergency department, where not all patients had a pain score recorded and not all patients consistently received prompt pain relief. Also in medicine the tools used to measure and monitor pain relief were minimal and did not include ways to support patients with communication difficulties.

Patients had access to adequate food and drinks. However, in the critical care unit a shortage of dieticians and speech and language therapists meant that some patients nutritional, swallowing and communications needs were not always responded to promptly.

Staff had access to training in order to maintain their skills, however sometimes it was difficult for them to access this due to staff shortages. Not all staff were receiving annual appraisals and supervision was under developed.

Multidisciplinary working was evident throughout the hospital.

Access to emergency care and clinical investigations was available across the whole week. The pharmacy service was open for limited hours on a Saturday and Sunday with an on call service outside of these hours. Some on-call cover was provided at weekends by allied health care professionals, although occupational therapists, speech and language therapists and dieticians worked Monday to Friday. The palliative care team was available from 9am to 5pm Monday to Friday, with access to a 24 hour advice line provide by the local hospice.

Consent to care was not consistently obtained in line with legislation and guidance including the Mental Health Act. In urgent and emergency care there was a lack of records of verbal or informal consent, and it was noted that only 62% of medical staff had received training on consent and the Mental Capacity Act. In medicine patients mental capacity had not been assessed and recorded where appropriate and it was not clear how best interest decisions had been made. Deprivation of Liberty Safeguards were not monitored and had expired without staff being aware, this increased the risk of patients having their liberty restricted without the appropriate safeguards in place.

Caring

Staff were providing kind and compassionate care and treated patients with dignity and respect. We rated it as good in all areas inspected.

Overall patients understood and were involved in their care and treatment. The exception to this was in the medical wards where many patients did not know the plan for their care and treatment and felt communication relating to this was poor.

Emotional support was available through the chaplaincy service, specialist staff and the volunteers who spent time sitting and chatting with patients.

Responsive

Bed occupancy was constantly over 92%, which is above the England average of 85.9% and above the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital.

Services were not always organised and delivered so that patients received the right treatments at the right times. The emergency department did not consistently meet waiting time targets. Some patients experienced long waits and there were frequent delays for patients who required admission because there were insufficient beds available in the hospital. At busy times the emergency department was overcrowded and patients queued in the corridor.

The emergency department observation unit frequently accommodated patients requiring a medical or surgical specialty bed when no suitable bed was available. These patients were not always clinically appropriate for this type of ward. The inappropriate use of the observation unit also meant that the ward was not being utilised effectively for maintaining patient flow within the emergency department.

Patients with mental health needs were not always assessed promptly by a mental health practitioner within the emergency department, often spending too long on the observation unit, which was not a suitable therapeutic environment for their potentially distraught, agitated or suicidal states.

Premises and facilities were not always fit for purpose. Some accommodation within the emergency department was cramped and was not conducive to the exchange of confidential information.

Some patients experienced delays in discharge and were unable to leave hospital when they were medically fit. A discharge team were in operation within the hospital working towards improving the discharge process for patients with complex needs. Difficulties in accessing packages of care in the community were delaying patient flow through the hospital.

The day surgery unit was used to accommodate patients overnight. This area did not meet many patient needs or provide basic facilities.

The hospital was not meeting the referral to treatment targets for any surgical specialties with the exception of ophthalmology. Whilst some waiting times were reducing, others were getting longer. Average waiting times were worse than those in the South of England NHS Commissioning area.

Cancelled operations were below (better than) the England average. There was an excellent pre-operative assessment service, a good theatre admissions lounge and discharge facilities, although these were sometimes crowded with people waiting for medicines and transport.

Staff supported people with learning disabilities to improve their experience of coming to hospital. Staff were kind and patient with people with dementia, but there were few facilities on the surgical wards, such as easy to read signage and dining areas to help frail confused patients.

There was limited evidence to show how complaints were being used to provide learning and produce changes to improve care and patient experience, with the exception of the maternity service.

Delays and cancellations as a result of bed unavailability in the critical care unit were minimal.

Access to the maternity service was efficient and responsive to the local population. Access and flow through the gynaecology inpatient service was affected by in response to intense trust wide service pressures.

The trust had involvement from other local services and organisations in the planning of meeting the needs for end of life care across the community and were continually looking at ways to work together to provide a co-ordinated service.

The end of life service was flexible and provided choice and accommodated individual needs for patient and carers.

Waiting times varied within the outpatients departments. There was no data collected on the percentage of patients waiting over 30 minutes to see a clinician.

There were challenges in meeting national performance indicators with some breaches in performance. There were backlogs in ophthalmology, dermatology and rheumatology and some delays in diagnostic imaging. Action to address this was not always timely

Well Led

Improvement initiatives within the emergency department had been developed, although staff had not been engaged with this process or changes in service provision. These initiatives were in their infancy and their success had yet to be evaluated.

Within the emergency department improvements were reactive and largely in response to recommendations from external bodies; they were not part of a well-developed strategy or vision for the future. There was limited evidence to show that patients’ views were being captured or acted on.

Risks to patient safety and quality within the emergency department were not fully captured in the service risk register and we could not be assured risks were regularly discussed, reviewed and escalated. Risks identified as a result of serious incidents were not always dealt with in a timely way.

Audits were not consistently used to drive service improvement in the emergency department.

Staff in the emergency department were committed and highly motivated. They worked well as a team and were well supported by their immediate managers although did not always feel engaged or empowered. Managers were visible, accessible and supportive within the emergency department.

The effectiveness of the divisional governance systems was not evident in some areas. Areas of concern had not always been identified and actioned. There was limited evidence of learning, change and improvement. There were a number of departmental meetings held, but in some areas it was unclear if and how these fed into the overall clinical governance and provided board assurance.

There was no governance structure in the critical care unit, with nobody leading on governance in the consultant team. Multi-professional clinical governance meeting were not held monthly and meeting minutes had not been regularly kept. Actions arising from meetings were not monitored effectively. There were limited examples of regular care and safety audits and performance measures being completed and reviewed.

Senior management were not always visible. The trust scored below the national average for the proportion of staff who staff reporting good communication between senior management and staff in the NHS staff survey results, 2014.

There was a theatre utilisation recovery programme being implemented and a programme to improve the inefficient use of the operating theatres. There was a range of clinical audits undertaken, but no reporting to the divisional board of audit results or action plans.

The critical care unit had a local vision and strategy document, but this did not appear in the overarching five year strategy for the directorate. The draft strategy document had not been submitted to, or reviewed by, the directorate board and only had local oversight. None of the areas within the strategy had clear information and ideas about how these developments could, and/or would, be achieved.

Financial constraints were limiting the ability to innovate and improve in some areas.

Within maternity and gynaecology, there were effective, risk, quality and governance structures in place. However, current processes did not ensure the trust had a complete overview of all serious incidents.

End of life care services were well led and had been seen as a priority with the development of a three year end of life strategy supported by a service review

There was not a clear vision or strategy within outpatients. There were specialities working in silos with limited working on the outpatient processes.

Diagnostic imaging had a clear governance process and staff were focused on providing a good service to their patients.

We saw several areas of outstanding practice including:

The diagnostic imaging team had some areas of outstanding practice, one of which, the palliative ascites drainage, was highly commended by the British Medical Journal (BMJ) in 2015. Innovative practice was seen with the introduction of the intra operative breast radiotherapy project.

In the critical care unit we were given examples of staff ‘going the extra mile’ for their patients, including a patient attending a family wedding in London, with transport being arranged by the unit and staff escorting the patient for the day.

In maternity services consultants provided specialist pre and post pregnancy counselling and support service to women. This and other specialist clinics developed to manage high risk pregnancies had been recognised as best practice. The lead consultant had won an All-Party Parliamentary Group Maternity Services Award during 2011. This service style had since been adopted by other maternity services across the country and show-cased at Harvard, USA.

Children were treated with respect and their ability to give consent for their own treatment was taken seriously.

However, there were also areas of poor practice where the trust needs to make improvements.

Take steps to ensure there are consistently sufficient numbers of suitably qualified skilled and experienced staff employed to deliver safe, effective and responsive care.

Ensure all staff who provide care and treatment to children in the emergency department are competent and confident to do so.

Make clear how patients’ initial assessment should be carried out by whom and within what timescale within the ED.

Monitor the time self-presenting patients wait to be assessed in the emergency depertment and take appropriate action to ensure their safety. This must include taking steps to improve the observation of patients waiting to be assessed so that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

Ensure that clinical observations of patients in the emergency department are undertaken at appropriate intervals so that any deterioration in a patient’s condition is identified and acted upon.

Risk assess and make appropriate improvements to the design and layout of the emergency department observation unit to reduce the risk of patients harming themselves or others.

Clarify the use of the observation unit, setting out its purpose, admission criteria and exclusion criteria to ensure that patients admitted there are clinically appropriate and receive the right level of care.

Ensure best (evidence-based) practice is consistently followed and actions are taken to continually improve patient outcomes.

Ensure chemicals and substances that are hazardous to health (COSHH) are secured and not accessible to patients and visitors to the wards.

Ensure sharps bins are used in accordance with manufacturer’s guidance to prevent the risk of a needle stick injury.

Ensure staff members are aware of the risk of cross infection when working with patients with isolated infectious illness.

Ensure risk assessment tools in place to identify risks of thrombosis, pressure damage, moving and handling, nutritional and falls are consistently completed and appropriate action taken.

Ensure National Early Warning Scores used to identify from a series of observations when a patient was deteriorating are appropriately actioned when high indicator scores were seen.

Ensure that patients with mental health issues on medical wards are appropriately managed.

Ensure appropriate review and action are undertaken when Deprivation of Liberty Safeguards have been put in place.

Ensure consistent compliance with the Mental Capacity Act. Ensure all appropriate surgical patients have their mental capacity assessed and recorded to ensure consent is valid, and the hospital is acting within the law.

Ensure patients’ records are fully completed and provide detailed information for staff regarding the care and treatment needs of patients.

Ensure the provision of single sex accommodation.

Ensure all areas of the premises and equipment are safe and secure, and patient confidential information is held securely at all times.

Ensure patients being admitted overnight to the day surgery unit have appropriate facilities which meet their needs, maintains their privacy and dignity, and reflects their preferences.

Provide a responsive service to reduce waiting times and waiting lists for surgery procedures. Theatre efficiency, access and flow, delays, transfers of care, and bed occupancy must be improved to ensure patients are safely and effectively cared for.

In addition the trust should:

Continue to take steps to improve patient flow, reduce overcrowding and reduce the time that patients wait in the emergency department.

Take steps to ensure that patients attending the emergency department and minor injury units are greeted and receive care and treatment in areas which are conducive the exchange of private information.

Clearly set out the objectives of initiatives designed to improve patient flow and the protocols which guide their use so that there is consistency of staff practice and engagement, and their effectiveness can be evaluated.

Undertake a staffing review of nursing and administration staff within the outpatients departments.

Consider the development of patient forums for outpatients and diagnostic imaging.

Ensure mortality and morbidity reviews are comprehensively recorded and lessons learned are shared locally and throughout the trust.

Ensure medical equipment and devices are replaced when scheduled within critical care.

Record non-compliance with the Core Standards for Intensive Care Units (2013) in critical care on the risk register to ensure continued focus on compliance.

Review the security of confidential patient records in critical care to ensure they are safe from removal or the sight of unauthorised people.

Develop an appropriate clinical audit programme in place so that patient care can be assessed, monitored and improved.

Review the provision of the critical care outreach team service, to ensure patients can receive timely critical care input in the wider hospital environment.

Review the role of the clinical nurse educator within critical care to ensure adequate time and resources are given to this essential post in line with best practice and the Core Standards for Intensive Care Units (2013).

Ensure critical care is included in major incident exercises.

Review the provision of dietitians and speech and language therapists to ensure critical care patients are adequately supported.

Review policies and procedures for critical care step down, handover and discharge to ensure patients are adequately supported at all stages of their care.

Review the provision of care to patients in critical care to ensure compliance with National Institute for Health and Care Excellence (NICE) guidance 83 in relation to some parts of patient rehabilitation, including discharge advice and guidance and follow-up clinics.

Review the process for HIV screening and results feedback in the critical care unit to ensure patients are kept informed.

Ensure critical care strategies and future plans are approved and incorporated into the overarching strategy of the division.

Ensure all equipment has up-to-date maintenance checks.

Improve the maternity and trust IT systems to remove duplication and increase accessibility.

Ensure gynaecology inpatients do not have their elective inpatient treatments cancelled as a result of other medical and surgical patients admitted to Beech ward.

Review actions to recruit and retain specialist gynaecology nurses.

Ensure processes are in place to reduce the risk of mothers taking an incorrect feed by mistake.

Ensure protocols are in place and followed to maintain confidentiality of patient information.

Ensure assessment charts can be used as designed to highlight patients at risk.

Ensure levels of safeguarding training and knowledge for medical staff is in line with national guidance.

Review the environment in which children are cared for and the exposure risk to adult behaviours.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During an inspection in response to concerns

Our visit to Great Western Hospital included time spent on seven wards, namely Jupiter, Saturn, Mercury, Linnet (the Acute Medical Unit), Neptune, Ampney and Woodpecker. We also visited the Day Surgery Unit and the operating theatre suite. We spent a day with the trust management and staff who contributed to the way the trust assessed and monitored the quality and safety of the service delivered.

We were accompanied on 28 October 2013 by the manager of Healthwatch Swindon and on 29 and 30 October 2013 by a member of our team of Experts by Experience. They spent time talking with patients, families and carers, and observing interactions between staff and patients. Our team of CQC inspectors and the specialist advisor spent time talking with staff from all disciplines, and with patients and their families. We reviewed records and inspected the wards and departments. Staff we talked with included some of the nurses and nurses in charge on each of the wards we visited, several nursing auxiliaries, several doctors and consultants, some cleaning staff, ward clerks, management and administration staff, and most of the executive team and leaders.

We found patients were treated with consideration and respect by staff. There were some examples of where privacy and dignity could have been improved, but most interactions we heard and saw were respectful. Patients were able to express their views and were given information about their care and treatment. Some patients, families and carers described times when they felt they did not know what was going on or had not been involved in decisions. However, we had more examples of this being done well. Patients told us: “the doctors are really good at keeping me informed, and my family. They [the family] just have to ring up to find out what’s happening” and “I have been kept in the loop at every stage and so has my wife. Even the anaesthetist told me what he was doing.”

Most patients’ experiences were of being assessed by experienced, well trained, and skilled clinical staff. Patients said they experienced effective, safe and appropriate care. We were told by a few patients about where they felt their needs had not been met safely at all times and where assessments of their care had not been effective. We also observed a number of the older patients were looking unkempt and needed more help with personal care. The hospital said it would review these cases and address any failings. We observed most of the care delivered with kindness, patience and professionalism. Patients told us: “the care has been superb; they’ve done everything they possibly can for me” and “when I came in it was a Saturday but they got me operated on straight away and I’ve had excellent pain relief ever since.” A number of patients and families told us they thought the hospital had “really improved” over the last few years.

We found some evidence of a lack of security of patients’ records in two wards in the hospital. Some of the records about patient assessments and their care plans were not always consistent, but in other areas the record-keeping was good.

Almost all the patients, families and carers we met and talked with, who numbered around 50, had concerns over staffing levels within nursing. The comments were strongest on the wards where there were predominantly older people. Patients said, for example: “there just are not enough staff, especially at night. The nurses are run ragged” and “there are not enough nurses. When I want something I have to ring and ring and ring. It’s horrible.” However, we also heard in another area: “I thought they had it well covered, I didn’t have to wait long if I rang the buzzer.” A number of patients told us they felt “guilty” about calling for nursing staff as “they are run off their feet.” Also, despite previous assurances, we heard again how the hospital was not effectively staffing the Day Surgery Unit. This was when this unit was being used to accommodate low-risk patients overnight following surgical procedures when beds were not available elsewhere.

There was evidence of how a lot of the problems we found in the wards in relation to poor record-keeping, a lack of some personal care, and responding well to calls for help, were attributable to low staffing levels within nursing. These problems were also affected by the high use of and ratio of temporary nursing staff to permanent nursing staff in some wards. Some of the nursing staff we met said it was harder for care and treatment to be delivered consistently due to the lack of experience of the ward otherwise brought by permanent nursing staff. The hospital trust was aware of a number of these issues already and steps were being taken to address these areas. But many of the planned improvements had not yet been realised and the current inadequate nursing-staff levels were having an effect on patient care.

Inspections of the wards on the first day of our visit found unacceptable levels of dust beneath patient beds. Effective delivery of cleaning was hindered by clutter in non-patient areas. Care and attention was given to infection prevention and control, with clinical staff wearing personal protective clothing, clean uniforms, and washing their hands appropriately. But, at this time, the hospital was close to reporting there were too many hospital acquired Clostridium difficile infections against national targets. The cleaning regime, which was vital to address the spread of this infection, was not delivered consistently thus reducing its effectiveness.

The hospital trust was run by a committed professional leadership team. There were dedicated staff who listened to, responded to, and reported upon complaints from patients or those who spoke for them. Incidents were analysed and trends identified so changes to practice could be implemented. There was a wide-ranging governance framework covering all areas of risk, quality and safety. However, some of the problems we found came from a number of processes and protocols not being fully effective. The hospital was, when compared with other similar hospitals, experiencing more than average patient falls. A governance committee had been established to look at reducing falls, but there was evidence of their work to reduce falls not being adopted for some vulnerable at-risk patients. There was not enough evidence to support how these basic principles or risk assessments for falls would be picked-up and addressed if they were not working.

There were errors in the medicines’ management policy. We observed an occasion where nurses were not completing prescription drug chart administration in accordance with known practice requirements. We were not assured as to how this problem would be picked up, as it appeared these types of errors were not captured or addressed through observation or audit.

We witnessed and saw evidence of incidents which were not reported. Where this related to incidents which we were told were a result of staff shortages, nursing staff said they felt they did not have time to add more administration work to their day among competing priorities. A member of nursing staff told us they felt what might have been seen as an incident was “normal life these days.” A number of other nursing staff agreed with that analysis. We met nursing staff who said the hospital’s escalation policy (to manage bed shortages) was right in principal. But they said the practical way staffing was organised and the knock-on effects that resulted were not delivering quality care for the patients. A complaint passed to us from a patient recently admitted to the Day Surgery Unit supported nursing staff concerns.

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During an inspection to make sure that the improvements required had been made

Great Western Hospital, Swindon, is part of Great Western Hospitals NHS Foundation Trust. We visited the hospital to review improvements the trust told us it had made to staffing levels in its maternity services. On our previous inspection of maternity services at this location in December 2012, we found staffing levels in relation to midwives were not always at acceptable levels to safely meet the needs of patients.

The trust sent us a series of action plans to outline how it was going to improve in these areas. We went back to the maternity department at the hospital to check on progress, and ask patients about their care and experiences of the service.

All the patients we met on this visit were pleased with the care they had received. One parent we met said: "without this hospital, I would not have a family." A family who had attended the maternity department on a number of occasions said: "we've always had good care. We can't really fault the place. The consultant treating us was 'world class'." Another patient said: "the care's been fantastic. Everyone's always helped." We were told by a patient: "I would recommend coming here to anyone." One family said the staffing levels in the daytime were "fine" but there seemed to be less staff available at night and "then they seem to be flat out." They said staff came, however, at all times and whenever they needed them, and said: "my faith in hospitals has been fully restored by this experience."

We found the trust had made sufficient progress in a number of areas to improve the staffing levels and skill mix. This included the women’s and children’s directorate raising the profile of this area of concern with the executive committee; the changing of staff shift patterns; recruiting additional staff; validating the model for determining safe staffing levels in maternity services; and putting in place an escalation policy for dealing with unplanned acute shortages of staff.

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During a routine inspection

We visited Great Western Hospital for this planned review on 11 December 2012 to look at the provision of maternity services. For this review we also visited Princess Anne Wing in Bath and the Trowbridge Birthing Centre (see other reports on those locations). We met senior staff on 18 December 2012 to review the trust's processes for assessing and monitoring the quality of the service (governance arrangements) for the maternity service. Our review at the hospital included looking at services in relation to antenatal, intrapartum and postnatal services. We also visited the co-located White Horse Birthing Centre.

Patients told us they were treated with privacy, dignity, confidentiality and respect but there were examples of when this did not happen as well as it should. Patients' comments about consultants, midwives and maternity care assistants included: "everyone's been really professional", "staff have been brilliant", and "everyone's been really kind and explained what's going on." One patient said: "everyone's really, really good. They go out of their way to help you."

We found people were cared for by experienced and caring staff. Medical records, assessments, and the management of clinical risks were good. Arrangements for governance were robust.

We were concerned about staffing levels and the impact this may have had upon care. A patient told us they felt staff were "stretched and worn out at times", but "went above and beyond to look after us."

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During an inspection to make sure that the improvements required had been made

We visited Great Western Hospital, Swindon, on 5 July 2012. We visited to review improvements the trust told us it had made in two areas of concern that arose from our inspection in December 2011. The trust had developed action plans to address these concerns. These plans were provided to us following our previous inspection.

We were accompanied on this inspection by the interim chief nurse.

We visited two wards in the hospital where, in December 2011, we were concerned about patients not having enough to drink, or this not being accurately recorded. We met and talked with patients on these wards and with the nursing and care staff on duty. A number of the patients we met were older people, some of whom were assessed as needing protection from the risks associated with poor hydration. The patients we met told us they were being given enough to drink and said staff had told them why it was important to take enough fluids.

We asked patients about their overall care at the hospital. One patient said: “care here is fabulous” and another said: “nothing is too much trouble”.

The staff we met on our visits to the wards showed dedication, professionalism and a caring attitude to patients. We found evidence to judge the hospital had made significant improvements to providing and monitoring fluids. Patients were being protected from the risks of inadequate hydration.

We went on to visit the operating theatres’ department where, in December 2011, we were concerned about the safety of theatre procedures and team communication. Great Western Hospital had 15 operating theatres to carry out elective, emergency or trauma surgery. Emergency and trauma theatres were set up to operate 24-hours-a-day. We met and interviewed members of the surgical team on duty during our inspection.

We focused at this visit upon use of the surgical safety checklists and associated protocols and procedures. Staff told us the use of checklists, surgery briefings and debriefing sessions had been re-launched within theatre. Staff said communication had “significantly improved” within teams. All members of the team felt valued and supported to deliver safe and quality care.

The action plan provided to address concerns in theatre practices following our inspection in December 2011 was extensive and detailed. All concerns were addressed in detail and actions allocated to a responsible member of staff.

The staff we met and interviewed in theatre demonstrated professionalism, knowledge and dedication to their respective roles. Patients were adequately protected from the risks of unsafe treatment during surgical procedures.

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During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

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During an inspection to make sure that the improvements required had been made

We visited the hospital to look at the improvements made in connection with three main areas:

• The use of ‘extra bed spaces’. These were additional beds which were being used, for example, to provide a fifth bed in a room designed for four people.

• The monitoring of fluid intake in relation to those patients who were at risk of dehydration if they did not receive the appropriate support.

• The occurrence of two ‘never events’. Never events are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’.

These areas were not directly related, but they were matters that the Trust had responded to by producing action plans with the aim of improving outcomes for patients.

We had heard adverse comments from patients about the extra bed spaces during our two previous visits to the hospital. The Trust has since carried out work to improve the facilities; however we were told that the use of extra bed spaces continued to cause difficulties for both patients and staff. Patients did not feel they were being treated on an equal basis and staff said that they received a lot of complaints.

We had been informed of two never events in recent months involving surgical procedures. One of these was a ‘wrong site’ event and the other involved the ‘wrong implant’ (a lens). During our visit we were told about the action being taken to reduce the risk of people being involved in surgery related never events. However, patients could not yet be confident that the appropriate preventative measures were being consistently implemented.

Patients’ fluid intake was not always being well monitored when we visited the hospital in July 2011. There was a risk that some patients were not receiving the support they needed with hydration. We looked at this again during the visit on 8 December 2011. The staff we spoke to were aware of the importance of monitoring people’s fluid balance, although there continued to be shortcomings in how this was being managed.

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During a routine inspection

People’s experiences of the hospital were mostly very positive. They told us that they were kept informed about their care and treatment. People felt that staff treated them with dignity and respect. In the outpatient department, for example, someone said that they were never made to feel uncomfortable. However, not everyone in the hospital experienced the same degree of choice, privacy and independence.

People’s needs were being assessed to make sure that they received the right treatment. Staff were described as ‘very helpful’ and ‘very professional’. One person commented ‘nothing is too much trouble, all care is given with a smile’.

Most people were happy with the meals. Staff helped people with their food and drinks. However, it was not always clear whether people had received the amount that they needed. People’s records did not always give a good or accurate picture of their care needs.

People experienced consistent care because the trust made arrangements with other providers and shared information. Medicines were being well managed and some people could look after their own if it was safe to do so.

People thought that the hospital was kept clean and they liked the modern surroundings. They said that the hospital was well equipped, although we found that items of medical equipment were not always being promptly serviced.

People said that they felt safe and there were usually enough staff on the wards. However staff were often busy, which meant that people might have to wait longer than they wanted to. One person commented ‘sometimes the nurses are rushed, but they are always polite and courteous’; other people expressed the same view.

Staff received a lot of training and worked as a team, which helped people to feel well cared for. Some staff worked on a relief basis; they did the same job, but they did not always receive the same level of support.

People felt that they could talk to staff if they had any concerns. The hospital had produced a lot of information and was keen to get feedback. However, people were not always aware of this information, and hadn’t always been told how they could pass on their views.

Overall, people felt that the hospital was meeting their needs well. The trust looked closely at its own performance to see how the service could be improved further.

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During a themed inspection looking at Dignity and Nutrition

Patients we spoke with made some very positive comments about the staff. They described staff as ‘very kind’, ‘lovely’ and as treating them ‘like a friend’. We were told that staff were busy and worked hard, and some patients said that more staff were needed.

Patients told us that staff took an interest in how they were feeling. However, they had not always been asked for information which would help staff to get to know them as people, with their own likes and dislikes.

We were told about the layout of the wards, which included a number of single rooms with en-suites, and other rooms for four patients. Patients liked the privacy and the facilities that these areas provided. However, we also met patients who said that their privacy and dignity was not being respected. One person described themselves as a ‘trolley patient, the fifth person in a four bedded room', as they were accommodated in an extra bed.

We heard positive comments about the choice and quality of meals. Most patients were satisfied with the meal arrangements. However, we were told about shortcomings, such as when a person got a meal that they hadn’t asked for, or felt that they needed more support.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.